Free Therapist Training›Family Therapy Toolkit›Intake Form
Last updated: November 11, 2026
A family therapy intake form gathers what a therapist needs before family sessions begin: who is in the family and who will attend, who has legal authority to consent for each child, how each person sees the problem, what has been tried, and whether it is safe for the family to meet together. It differs from an individual intake in two ways. Several people answer, often differently, and the safety screen has to reach each adult privately.
The form below has three parts: the family, a safety screen to complete with each adult alone, and the agreements to review together. California notes on minor consent, parent access to records and mandated reporting are labeled. A completed intake for an invented family follows it. The form is part of the Sentio MFT program's free family therapy toolkit.
An optional template from the Sentio MFT program's family therapy toolkit, free to adapt.
Download the PDFCopy in Google Docs
Part A. The family
| Name | Age | Relationship to the identified patient | Gender | Lives in the household? | Attending sessions? |
|---|---|---|---|---|---|
| Item | Entry |
|---|---|
| Date of first contact; referral source | |
| Who is the client | The family as a whole / A couple / An individual, with other family members taking part as collaterals |
| Identified patient, if the family or the referral names one | |
| Billing | Who pays; if a health plan is billed, the member whose condition the family sessions treat |
| Custody and legal decision-making for each minor | Legal and physical custody; any court order (copy on file: yes / no); whether the order requires both parents' consent for health care (yes / no); who signed consent |
| Minor consenting on their own behalf | Yes / No. If yes, the maturity finding and the parent contact entry (see the California notes) |
| Reason for seeking help, in each person's words | One line for each person present |
| When the problem began; what else was happening then | |
| What the family has tried | |
| Previous and current treatment | Therapists, physicians, psychiatrists, hospital stays, medications |
| School and work | For each member: school, grade and any difficulties; work and schedule |
| Health | Serious illness, disability, pregnancy, sleep, appetite |
| Alcohol and drug use | For each member, including adolescents |
| Culture, language and faith | Languages spoken at home, interpreter needed, identities and beliefs members want the therapist to know |
| Strengths and supports | What the family does well; who they can call on |
| Each person's goal for therapy | One line for each person present |
Part B. Safety screen (ask each adult alone, and each adolescent alone for part of the time)
| Screen | Entry |
|---|---|
| Separate interviews | Each adult partner seen alone before the first joint session: yes / no, dates. Adolescents seen alone for part of the first session: yes / no |
| Fear and violence between adults | Asked of each adult alone: being afraid of a partner; being hit, pushed, choked or threatened; being controlled, monitored or kept from money, family or friends; forced sex |
| Violence toward or in front of children | Harm, threats or neglect; children present during violence between adults |
| Risk to self | Suicidal thoughts, plans, past attempts or self-harm, for each member old enough to be asked |
| Risk to others | Threats, weapons in the home, past violence |
| Mandated report | Any report made or considered, with the agency, date and time |
| Decision | Joint sessions appropriate / Individual sessions first / Referral to specialist services. Safety plan written: yes / no |
Part C. Agreements
| Topic | What the family is told and agrees to |
|---|---|
| Who the client is | Whether the therapist's client is the family, the couple or one member, and what that means for each person present |
| Confidentiality and its limits | What stays in the room; the legal exceptions, such as suspected abuse and serious danger |
| Information shared in individual sessions | Whether the therapist will keep a secret from other family members, and if not, how it will be handled |
| Records | Whose record the sessions are kept in, and who may see or release it |
| Fees | Who is responsible for fees, and for which sessions (see the California notes on treatment a minor consents to) |
| Recordings | Whether sessions are recorded for supervision or training, with written consent from each adult and from minors who consent to their own care |
| Signatures | Each adult attending; a minor 12 or older who consents to their own treatment; date |
California notes
Minor consent. A minor 12 or older may consent to outpatient mental health treatment or counseling if, in the opinion of the attending professional person, the minor is mature enough to participate intelligently (Family Code 6924(b); Health and Safety Code 124260(b)(1)). A parent or guardian who does not take part in that treatment is not liable to pay for it, and one who takes part is liable only for the services they took part in (Family Code 6924(e); Health and Safety Code 124260(d)).
Parent involvement. Treatment under those sections includes the parent or guardian unless the professional person, after consulting with the minor, decides involvement would be inappropriate. The record must state whether and when the professional tried to contact the parent or guardian and whether the attempt succeeded, or why contact would be inappropriate (Family Code 6924(d); Health and Safety Code 124260(c)).
Associates, trainees and interns. Associates and trainees working under the required supervision are among the professional persons who may treat a minor on the minor's own consent (Health and Safety Code 124260(a)(2)). An MFT trainee, clinical counselor trainee, psychology trainee or social work intern who does so notifies their supervisor within 24 hours, or immediately after the session if the initial assessment indicates that the minor is a danger to self or others (Health and Safety Code 124260(b)(2)).
Joint legal custody. Under a joint legal custody order, either parent acting alone may exercise legal control of the child except where the order requires both parents' consent, so read the order's terms on health care (Family Code 3083).
Parent access to records. A parent or other representative of a minor is not entitled to inspect or copy the minor's records, including clinical notes, where the minor has their own right of inspection, where the provider determines access would have a detrimental effect on the provider's relationship with the minor or on the minor's physical safety or psychological well-being, or where the records relate to outpatient mental health care that a minor old enough and able to consent obtained on their own consent (Health and Safety Code 123115(a)). A parent may not be denied access to a child's records because they are not the custodial parent (Family Code 3025). Our guide to minor consent and parent access to records covers both rules.
Mandated reporting. Suspected child abuse or neglect is reported by telephone immediately or as soon as practicably possible, with a written report within 36 hours (Penal Code 11166). Mandated Reporting Deadlines for California Therapists lists every clock.
What Does a Completed Family Intake Look Like?
The intake below was completed with the Hale-Carter family, the invented blended family used throughout the toolkit, over the first session and two short individual interviews. Notice that each person's view of the problem is recorded separately and that the adults were screened alone before the family met together.
| Name | Age | Relationship to Ava | Gender | Lives in the household? | Attending sessions? |
|---|---|---|---|---|---|
| Ava Carter | 15 | Identified patient | Girl | Yes | Yes |
| Jenna Hale | 41 | Mother | Woman | Yes | Yes |
| Chris Hale | 44 | Stepfather | Man | Yes | Yes |
| Ben Carter | 12 | Brother | Boy | Yes | Some sessions |
| Tyler Hale | 17 | Stepbrother | Boy | Half-time | Invited to session 3 |
| Mark Carter | 43 | Father | Man | No (Arizona) | Phone contact with consent |
| Item | Entry |
|---|---|
| Date of first contact; referral source | October 12, 2026; Ava's school counselor |
| Who is the client | The family. Jenna, Chris, Ava and Ben are clients; Mark and Tyler take part as collaterals. |
| Identified patient | Ava, named in the school counselor's referral |
| Billing | The family's health plan, billed for family sessions as treatment of Ava's condition. Jenna is responsible for fees. |
| Custody and legal decision-making | Jenna and Mark share joint legal custody under their 2016 judgment, which does not require both parents' consent for health care; Jenna has primary physical custody. Copy on file: yes. Consent signed by Jenna. |
| Minor consenting on her own behalf | No. Ava attends with her mother's consent and agreed to come. |
| Reason for seeking help | Jenna: "Ava and Chris can't be in a room together." Chris: "Nobody backs me up." Ava: "Everyone's on my case since the move." Ben: "It's loud." |
| When the problem began | September 2026, a month after Jenna began night shifts and Chris took over evenings |
| What the family has tried | Taking Ava's phone; grounding; Jenna calling home from work to mediate |
| Previous and current treatment | Ava saw a grief counselor for eight sessions in late 2019 and early 2020, after her grandfather died. No current medications. |
| School and work | Ava, 10th grade, failing two classes, missing first period two or three times a week. Ben, 7th grade, no concerns. Jenna, nurse, nights. Chris, contractor, days. |
| Health | No serious illness. Ava sleeps after 1 a.m. on school nights. |
| Alcohol and drug use | Ava denies use. Chris drinks two beers on weekends. Gary, Chris's father, has been sober since 2010. |
| Culture, language and faith | English at home. The family stopped attending church after the 2021 move; Jenna would like to return. |
| Strengths and supports | Jenna and Ava are close; Chris is steady with Ben; Diane helps with childcare; the school counselor knows Ava well. |
| Each person's goal | Jenna: "Peace in the evenings." Chris: "To be treated like a parent." Ava: "For Chris to back off." Ben: "Less yelling." |
| Screen | Entry |
|---|---|
| Separate interviews | Jenna and Chris each seen alone on October 15, 2026; Ava seen alone for 15 minutes in session 1 |
| Fear and violence between adults | Both deny fear, physical violence, threats and controlling behavior. Arguments are verbal; Chris leaves the room when angry. |
| Violence toward or in front of children | None reported by any member. Ava says Chris has never touched her and that the shouting "goes both ways." |
| Risk to self | Ava denies suicidal thoughts now and in the past. No self-harm. Screen repeated at each session for four weeks. |
| Risk to others | No threats, no weapons in the home |
| Mandated report | None indicated |
| Decision | Joint family sessions appropriate, with a 10-minute individual check-in for Ava at each session. No safety plan needed at this time. |
Part C was reviewed with Jenna, Chris and Ava. The family chose a policy that the therapist will not keep secrets that affect the family's safety or the goals of treatment, and will help a member decide how to share them. Signed by Jenna and Chris; Ava signed to show she agreed.
What Should a Family Therapy Intake Cover?
Start with membership and authority: who is in the family, who lives where, who will attend, and, for each minor, who holds legal custody and who signed consent. Ask for a copy of any custody order that bears on health care decisions, and note where the minor has consented on their own behalf. Then record the problem as each person describes it, in their own words, because the differences between descriptions are the first map of the family's pattern. When the problem began and what else changed at that time often matters more than its history.
Add what the family has tried, previous and current treatment, school and work, health, alcohol and drug use, the family's culture, languages and faith, and its strengths. Close with each person's goal. A family whose members want different things from therapy is common, and writing each goal down is the first step toward a plan everyone can sign.
Screening for Violence Before Family Sessions
Couple and family therapy can put a person at risk if a partner is violent or controlling, because what is said in a joint session can be punished at home. Michele Bograd and Fernando Mederos, writing in the Journal of Marital and Family Therapy in 1999, argued that every couple should be assessed for battering as part of the standard intake, and that a single risk factor rules out conjoint therapy. A 2011 systematic review in the same journal found that most research on universal screening came from medical settings and that family therapy had not yet adopted the practice systematically. The federal treatment guide on family therapy for substance use disorders gives the same direction as Bograd and Mederos: assess past and current violence before couple or family counseling, treat a current risk of partner violence as a reason not to meet jointly, and handle a private disclosure of violence separately rather than carrying it into the next family session. A 2008 review of couples treatment for partner violence describes programs that pair joint sessions with individual interviews, including one whose evaluation begins with individual interviews that explore violence and apply exclusion criteria, and a 2022 review of couples therapy and partner violence recommends meeting each partner separately and privately to assess violence before joint work.
Part B of the form follows that approach. See each adult partner alone before the first joint session, and ask about fear, physical violence, threats, controlling behavior and forced sex in plain, specific language. When the interview is by video, first confirm that the person is alone and cannot be overheard, since a partner may be listening during a virtual visit. Ask adolescents some questions alone as well. If an adult discloses violence or fear, do not move to joint sessions: assess safety, help the person make a safety plan, and refer to services that specialize in partner violence. Repeat the screen if the picture changes. The US Preventive Services Task Force names brief tools such as HARK, HITS and WAST. These are published instruments, and HITS, for example, is copyrighted by its developer, so link to the published version rather than copying an instrument into your own forms unless its owner's terms allow that.
Consent When the Client Is a Child
In most family therapy, a parent or guardian consents to a child's treatment. When parents are divorced or separated, the custody order decides who holds that authority, so ask for it at intake rather than assuming. In California, a parent with joint legal custody may act alone unless the order requires both parents' consent for that decision (Family Code 3083), which is why the form asks what the order says about health care. California also lets a minor consent on their own behalf: a minor 12 or older may consent to outpatient mental health treatment or counseling if, in the opinion of the attending professional person, the minor is mature enough to participate intelligently (Family Code 6924; Health and Safety Code 124260). When a minor consents under those sections, treatment includes the parent or guardian unless the professional, after consulting the minor, decides that would be inappropriate, and the record must say whether and when the professional tried to contact the parent, whether it succeeded, or why contact would be inappropriate. A parent or guardian who does not take part in that treatment is not liable to pay for it, and one who does take part is liable only for the services they took part in.
Our guide to minor consent and parent access to therapy records in California sets out both statutes, the 2024 change that aligned them, and the documentation they require.
Who Can See a Family's Records?
Agree at intake on whose record the sessions are kept in and who may see it, because family members will ask. Under California law, a parent or other representative of a minor is not entitled to inspect or copy the minor's records, including clinical notes, when the minor has their own right to inspect them, when the provider determines that access would have a detrimental effect on the provider's relationship with the minor or on the minor's physical safety or psychological well-being, or when the records relate to outpatient mental health care that a minor old enough and able to consent obtained under the minor consent statutes (Health and Safety Code 123115). A parent may not be refused access to a child's records only because they are not the custodial parent (Family Code 3025).
The intake is also where mandated reporting is first discussed. Tell the family the limits of confidentiality before anyone discloses, and if a report is required, make it on time: in California, suspected child abuse is reported by telephone immediately or as soon as practicably possible, with a written report within 36 hours (Penal Code 11166). Mandated Reporting Deadlines for California Therapists lists each clock.
Practice next: holding boundaries
The intake is the first place a family tests the frame: a parent who answers for a teenager, a grandparent who wants to stay, a member who asks the therapist to keep a secret. Holding the structure kindly sets the tone for every session after it.
Watch episode 14: Systemic BoundariesSystemic therapy pagePractice set in the toolkit
Rehearse the boundary statements in the toolkit's practice set, then rehearse how you will explain your policy on secrets in two or three sentences.
Keep reading
Minors in California Therapy: Who Consents, and Who Can See the Records, the consent and records statutes in full
Family Therapy Progress Note Template, who the client is in the record, and how HIPAA treats family session notes
Genogram Template, the family history the intake opens
Free Family Therapy Toolkit, all eight templates on one page
Frequently Asked Questions
What should a family therapy intake form include?
Who is in the family and who will attend, custody and consent for each minor, each person's view of the problem and goal, what has been tried, previous and current treatment, school and work, health and substance use, culture and supports, a safety screen completed with each adult alone, and the agreements on confidentiality, secrets, records and recordings.
Should I interview family members separately at intake?
Interview each adult partner alone before joint sessions to screen for violence and fear, and give adolescents some time alone as well. If violence or fear is disclosed, do not begin joint sessions: assess safety, help the person make a safety plan and refer to services that specialize in partner violence. Consider joint work only if a careful assessment finds no current risk.
Can a 12-year-old consent to therapy in California?
Yes, on a finding of maturity. California Family Code section 6924 and Health and Safety Code section 124260 let a minor 12 or older consent to outpatient mental health treatment or counseling if, in the opinion of the attending professional person, the minor is mature enough to participate intelligently.
Can a parent see their child's therapy records in California?
Not always. Health and Safety Code section 123115 provides that a parent or other representative is not entitled to inspect or copy a minor's records when the minor has their own right to inspect them, when the provider determines access would have a detrimental effect, or when the records relate to care the minor obtained on their own consent under the minor consent statutes.
Do I need a policy on secrets in family therapy?
Decide on one before the first session and explain it at intake: whether you will keep information one member shares privately from the others, and if not, how you will help that member share it. Writing the policy into the intake agreements avoids a dilemma later.
References
Bograd, M., & Mederos, F. (1999). Battering and couples therapy: Universal screening and selection of treatment modality. Journal of Marital and Family Therapy, 25(3), 291–312. https://doi.org/10.1111/j.1752-0606.1999.tb00249.x
California Family Code § 3025. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM§ionNum=3025
California Family Code § 3083. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM§ionNum=3083
California Family Code § 6924. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=FAM§ionNum=6924
California Health and Safety Code § 123115. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=123115
California Health and Safety Code § 124260. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=124260
California Penal Code § 11166. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=PEN§ionNum=11166
Keilholtz, B. M., & Spencer, C. M. (2022). Couples therapy and intimate partner violence: Considerations, assessment, and treatment modalities. Practice Innovations, 7(2), 124–137. https://doi.org/10.1037/pri0000176
McCollum, E. E., & Stith, S. M. (2008). Couples treatment for interpersonal violence: A review of outcome research literature and current clinical practices. Violence and Victims, 23(2), 187–201. https://doi.org/10.1891/0886-6708.23.2.187
Substance Abuse and Mental Health Services Administration. (2020). Substance use disorder treatment and family therapy: Updated 2020 (Treatment Improvement Protocol [TIP] Series No. 39, Publication No. PEP20-02-02-012). https://www.ncbi.nlm.nih.gov/books/NBK571079/
Todahl, J., & Walters, E. (2011). Universal screening for intimate partner violence: A systematic review. Journal of Marital and Family Therapy, 37(3), 355–369. https://doi.org/10.1111/j.1752-0606.2009.00179.x
US Preventive Services Task Force. (2025). Screening for intimate partner violence and caregiver abuse of older or vulnerable adults: US Preventive Services Task Force recommendation statement. JAMA, 334(4), 329–338. https://doi.org/10.1001/jama.2025.9009
